Provider Demographics
NPI:1235836677
Name:FONDREN, KAITLIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KAITLIN
Middle Name:
Last Name:FONDREN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9700 PARK PLAZA AVE UNIT 106
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2286
Mailing Address - Country:US
Mailing Address - Phone:502-429-5431
Mailing Address - Fax:
Practice Address - Street 1:9700 PARK PLAZA AVE UNIT 106
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2286
Practice Address - Country:US
Practice Address - Phone:502-429-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY282393103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical